2009 Joint Commission Standards for Emergency Management

1. 2009 Joint Commission Standards for Emergency Management October 14th, 20081:00-2:30 p.m. EDT LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 1

2. This educational web cast is sponsored by American Hospital Association Solutions and LiveProcess Disaster Readiness & Incident Command Solutions. LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. Web cast Sponsor 2

3. Today’s Presenters Brad Hunter, Director - AHA Solutions, Inc. Jerry Gervais, Associate Director, Standards Interpretation Group - The Joint Commission Mitch Saruwatari, VP Quality & Compliance - LiveProcess Michael Neyer, Director of Customer Support - LiveProcess 3

4. Education Research Products and Services Due Diligence Products and Services: Offer a select number of AHA reviewed and endorsed solutions that facilitate efficiency, cost savings, patient satisfaction & overall quality within hospitals. Education: Timely, relevant live and electronic educational opportunities. Focused on key operational issues, trends and challenges. AHA Solutions – A Resource to Hospitals Research and Market Analytics: Hosting focus groups, conducting market surveys and delivering national studies on key operational trends. Distribute knowledge directly to hospitals Due Diligence:Analyze market needs and pursue a comprehensive due diligence strategy to review and assess vendors and consultants. 4

5. AHA Solutions – A Resource to Hospitals Mission: To be the trusted resource for education, information and products and services that foster operational excellence in hospitals Exclusive rights to award the AHA endorsement Facilitating Executive workshops focused on Strategic Alignment Focus areas guided by Advisory Committees and Board of Directors and include: Human Resources & Employee Benefits Patient Flow Finance & Operations Information Technology The AHA Endorsement signifies that a product or service has passed our tests for quality and that the vendor behind it meets our strict criteria for quality, stability and customer service. 5

6. Why Endorse LiveProcess Disaster Readiness & Incident Command Solutions Innovative technology Impressive expertise Commitment to healthcare Designed specifically for hospitals Comprehensive knowledge of emergency/incident management regulations Leadership team played an integral part in creating HICS IV (Hospital Incident Command System) and NIMS (National Incident Management System) 6

7. Why Is It Needed? Enhanced patient, employee and community safety Reduced organizational risks Peace of mind by providing a consistent and reliable organization planning and response process Confidence that a timely response is initiated every time an emergency occurs Better and timelier decisions Reinforcement of competency using a simple and automated disaster exercise program Organizational efficiencies and savings Improved safety and access for the community served 7

8. 2008 Emergency Preparedness Update Jerry Gervais Associate Director, Standards Interpretation Group, The Joint Commission 8

9. Difficult Standards The following Standards, (and the associated Elements of Performance), have proven to be the most difficult to achieve and be in compliance with, during the first 6 months of survey during 2008 That is why The Joint Commission announced that it would extend the time for compliance until 12/31/08 9

10. EC.4.11, EP’s 9 & 10 EP 9 - Hospital keeps a documented inventory of the assets & resources it has on site EP 10 - Hospital establishes methods for monitoring consumption of assets during emergency operations 10

11. EC.4.12 Emergency Operation Plan (EOP) • Develops a plan which addresses the six critical functions • Requires an Incident Command Structure • Consistent with community ICS • Identifies procedures for activating and terminating emergency operations • Describes staffing patterns (who they report to when EOP activated) 11

12. EC.4.12 Emergency Operation Plan (EOP) • EOP identifies organization's capabilities for 96 hours without being able to be supported by the community • EOP establishes response efforts when the organization cannot be supported by the local community for 96 hours for managing the six critical functions • Evacuation is an acceptable strategy (but not always the most desirable!) 12

13. EC.4.12, EP 6 > QUESTION: • Are we supposed to stand alone for 96 hours? • e.g., stockpile supplies on hand, etc? • or can we just say we have enough to last 96 hour and then evacuate, etc? • Why did the Joint Commission pick 96 vs. 72? 6. The EOP identifies the organization’s capabilities and establishes response efforts when the organization cannot be supported by the local community for at least 96 hours in the six critical areas. 13

14. Revised EP 6 Note • An acceptable response effort could include: • Conservation of resources • Curtailment of services • Supplementing of resources from outside the local community • Staged evacuation • Total evacuation 14

15. Striving for 96 Hours Normal - Generator Fuel Emergency – shut down some floors, cancel elective surgeries Normal – Clinical Supplies Emergency – curtail some services, discharge some patients Normal – Water (Sanitary) Emergency – water conservation (sponge baths, waste disposal) 0 hrs 24 hrs 48 hrs 72 hrs 96 hrs 15

16. EC.4.12, EP 6 > ANSWER • The main point is that the organization knows their capabilities • Responds according to this knowledge • Regarding the 96 vs. 72 hours • The Joint Commission onsite evaluations indicated that 96 hours was a more realistic expectation • This was confirmed during Standards Review 16

17. EC.4.12, EP 6 • This standard is not a mandate from The Joint Commission to remain open for 96 hours during or post, disaster! Or, to stockpile supplies for 96 hours • It is a requirement to engage in a planningeffortto evaluate the organization’s capabilities for 96 hours and to adjust their Emergency operations plans accordingly, after they understand their true capabilities. Then communicate this information to the people in the community they serve who are responsible for disaster planning 17

18. EC.4.13, EP 7 • The hospital develops methods for communicating with identified alternative sites of care 18

19. EC.4.14, EP’s 8 & 10 • Sharing of resources & assets with health care organizations outside the community during a regional or prolonged disaster • Transporting patients, their meds & equipment, and staff, to alternate care sites when the existing environment cannot support patient care 19

20. EC.4.15, EP’s 2 & 3 • The hospital identifies the roles of communitysecurity agencies & defines how they will coordinate with them during emergency operations • The hospital identifies processes required for handling hazardous wastes & materials during emergency operations 20

21. EC.4.16, EP’s 2 & 3 • Staff are trained for their assigned roles & responsibilities • The hospital communicates to licensed independent practitioners their roles in emergency response and to whom they report 21

22. EC.4.17, EP 4 • Fuel required for building operations or essential transport activities 22

23. EC.4.18, EP’s 4,5,6 • The mental health needs of its patients • Mortuary Services • Plans for documenting & tracking patient’s clinical information 23

24. Relief: Until 12/31/08 • The following 15 EPs will not impact your accreditation status • These EPs will be cited, but not counted toward an accreditation decision • EC.4.11 EP 9 & 10 • EC.4.12 EP 6 • EC.4.13 EP 7 • EC.4.14 EP 8 & 10 • EC.4.15 EP 2, 3 & 5 • EC.4.16 EP 2 & 3 • EC.4.17 EP 4 • EC.4.18 EP 4, 5, & 6 24

25. Common Theme? • All of the above require inter-action and coordination with people, agencies, & other organizations outside of the hospital and not under their direct control • The amount of time necessary to plan, develop, and agree on processes takes longer periods of time, or may not have been in place prior to the new standards 25

26. What Does 2009 Bring? • Separate Chapter for Emergency Management in the Accreditation Manual • No new requirement for 2009 (same as 2008) • New numbering system for the standards • New scoring system for all standards 26

27. Why a Separate Chapter? • The Joint Commission feels very strongly that emergency management is such an important issue to communities and to the healthcare process that it must be given this level of prominence • This also addresses repeated requests from emergency planners at the hospitals and in the communities to give stronger emphasis to the need for preparedness, response, and recovery from disasters and to demonstrate that this is not just an “Environment of Care” effort, but crosses all areas of a hospital’s operations 27

28. Addressing Compliance: Solutions Mitch Saruwatari VP Quality & Compliance, LiveProcess Michael Neyer Director of Customer Support, LiveProcess LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 28

29. Compliance Issues Many Recent Changes Limited Staffing Resources No Central Repository for All Emergency Management Compliance Activities Duplicated Effort Simple Tracking and Scoring Needed High-Level Strategic Planning Needed LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 29

30. Tracking Tools LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 30

31. Reporting & Trending LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 31

32. Desired Outcomes Reduce Staff Time Improve Compliance Scores Provide Higher Visibility Create Linkages to All Components of the Emergency Management Program LiveProcess Disaster Readiness & Incident Command Solutions have the exclusive endorsement of the AHA. 32

33. Emergency Preparedness. Peace of Mind. www.liveprocess.com 33

34. Question & Answer Session LiveProcess Disaster Readiness and Incident Command Solutions have the exclusive endorsement of the American Hospital Association (AHA). 34

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36. For More Information Brad Hunter AHA Solutions, Inc. 312.895.2527 bhunter@aha.org Jerry Gervais The Joint Commission jgervais@jointcommission.org Mitch Saruwatari LiveProcess 818.312.0131 msaruwatari@liveprocess.com Michael Neyer LiveProcess mneyer@liveprocess.com For more information on AHA Solutions, please visit www.aha-solutions.org For more information on LiveProcess please visitwww.liveprocess.com If you have questions regarding this web cast, please email technologysolutions@aha.org 36